Vinayak Bapat

25th May 2017

3865

Vinayak Bapat

Vinayak—“Vinnie”—Bapat (New York Presbyterian Hospital/Columbia Medical Center, New York, USA) was all set to become a fighter pilot in the Indian air force until his father’s major heart attack led him on the path to becoming a cardiothoracic surgeon instead. He talks to Cardiovascular News about a transcatheter aortic valve implantation (TAVI) case that saved two lives, the development of transcatheter mitral valve implantation (TMVI), and his “valve-in-valve” app.

Why did you decide to go into medicine and, in particular, why cardiothoracic surgery?

I always wanted to become a pilot in Indian air force and, hence, I joined a military school at age of 11. However in 1985, my father suffered a major heart attack and I decided to pursue a “civilian life” so as to stay close to my parents. Daily visits to the coronary care unit and later, weekly visits to my father’s cardiologist convinced me that a career in cardiac surgery would be the best thing for me. I thought cardiac surgery was intriguing and complex—similar to how I imagined flying fighter planes would be! Therefore, aged 16, I decided that I would be a cardiac surgeon!

Who you have been your career mentors?

I went to one of the best medical schools in India: the King Edwards Memorial VII in Mumbai. In my second year, the chief of Department of Surgery, Dr Samsi—who was also the most well-known surgeon in India at that point—made the biggest impression on my budding surgical mind. One of his phrases “the best surgeon is the one who knows when not to operate” still rings in my ears every time I assess a complex situation. Drs Heman Kulkarni, Avinash Supe and Anil Tendolkar also helped me become a good doctor and surgeon. They, too, are all very well-known surgeons but, above all, they are great teachers and mentors. Dr Supe is now dean of my medical school and a devoted teacher while Dr Anil Tendolkar is a legend in India. I consider myself fortunate to have been his student.

In the UK, Mr Graham Venn was a mentor and gave me stability, confidence and has supported me throughout my career without hesitation. This was critical during my part in the early days of TAVI, which was challenged and frowned upon by surgical community at the beginning. Without Mr Venn’s backing, I do not think I would have achieved what I have done in this field.

Finally, I would like to mention the “3Ms”: Martyn Thomas, Mike Mack and Marty Leon, all of whom who have encouraged my enthusiasm in innovation and provided me with support and guidance throughout the last decade. I hope to be as inspiring to the upcoming generation of surgeons as they have been to me.

During your career, what has been the most important development in cardiothoracic surgery?

The birth of transcatheter valves, which I think has been the most important development since the heart transplant. TAVI has literally shaken the world of cardiac surgery—it made us surgeons think differently, embrace the unknown, and learn new skills. Importantly, it made us modify our own practices, which were set in stone! Challenging convention has now become the convention. For example, TAVI has introduced new concepts such as catheter skills, imaging and the heart team approach, among others, to me. Most importantly, it provided me with an opportunity to innovate and educate.

I have now managed to export the concept of the heart team to other areas of surgical practice, and TAVI has also helped me introduce new surgical techniques in UK such as “keyhole aortic valve surgery”. I have taken my team to USA on two occasions to train in this technique. Because I recognised the benefits of the heart team for all aspects of my practice, I took my anaesthetist, perfusionist and head nurse with me to train. Also, I am proud to say that we have trained other centres in UK to start their programmes in this keyhole technique rather than keeping it to St Thomas’.

You have done substantial work in the field of TMVI. How close are we to having a commercially-available device?

My prediction is five years. None of the devices currently in development will completely address the needs of the majority of patients that we hope to treat with TMVI. At present we know that once implanted, TMVI devices are effective; what we now have to figure out is how to implant them reliably in every patient and with the least risk.

Why has developing TMVI been more difficult than developing TAVI?

There are two challenges: first, physiological—the mitral valve is larger in size and a much more complex structure than the aortic valve, closing pressure in the mitral valve is much higher, mitral valve disease is heterogenous, and finally there is proximity to the left ventricular outflow tract (which could be obstructed after transcatheter mitral valve repair); second, technological—a larger valve means that large calibre delivery systems, complex anchoring or stabilising mechanisms are required to retain the valve, frame integrity needs to more robust as the devices are large and usually have multiple components, and finally how the interaction between a larger device covered in fabric and blood could influence clotting and haemolysis is still unclear.

Of the research you have been involved with, what do you think has had the biggest impact on clinical practice?

Without a doubt, my work in the field of valve-in-valve has had the biggest impact. When we first started performing valve-in-valve procedures, I realised how little information was available for the valves that we were treating and how they interacted with TAVI devices. Surgeons knew what the valves looked like but not how they looked under fluoroscopy, while the cardiologists probably did not know much about heart valves. I had a table of all valve sizes and their dimensions in my office before TAVI even started and I started using these as a reference guide. However, these charts were made for surgical procedures rather than valve-in-valve.

I decided to collate allof this information so that it could be used for TAVI operators. However, what started as a simple exercise to catalogue various heart valves implanted in the last two decades soon became a fully fledged research project that is still ongoing.

We took a stepwise approach to first describe fluoroscopic appearances of surgical and TAVI valves, then to introduce the concept of the “True ID”—the true internal diameter—to help size the valves correctly for the procedure, and finally introduced the concept of “neo-annulus” to help position the TAVI valve optimally within different surgical valves.

The best part of this project was interacting with the brilliant research and developed groups from all of the valve manufacturers, and this work led to the creation of the valve-in-valve (“VIV”) app. It not only provides a practical guide to users all over the world, with robust information about valve-in-valve procedures, but also provide steps for how to perform them. It is still free to download, which means it is unbiased educational tool that anyone can download and use.

As new TAVI devices emerge and new frontiers such as valve-in-rings become common, we hope our work will continue to influence good patient outcomes. We are now in the process of collating information on computed tomography (CT) appearances of these valves with Jonathon Leipsic (Centre for Heart Valve Innovation, St Paul’s Hospital, University of British Columbia, Vancouver, Canada) and his team, and we hope this will enhance the information available to users of the app.

How did you, as someone who is not a professional software engineer, develop the app?

My daughter suggested I developed an app after I commented about how much time I was spending replying to people who were sending me emails with enquiries about how to perform valve-in-valve procedures. I had no idea about how to go about it, but I created a Powerpoint presentation with some ideas about what information the app could contain and sent it to Dr Leon for his viewpoint. He replied in less than five mines and told me it was a brilliant idea!

My hospital’s commercial team helped me and I received a grant of £7000 from the Biomedical Research Centre at St Thomas’ hospital to start the work.

The material in the app had to be collected and collated, which included thousands of images. This involved multiple visits to the cath lab for fluoroscopic images and having a make-shift photography studio—in my office. Countless hours were also spent with research and development teams of all the heart valve manufacturers to discuss recommendations.

Alex from UBQO, who developed the app, was very patient and guided me through the entire build—we created the app in three weeks! Mark Monaghan (Department of Cardiology, King’s College Hospital, London, UK), Martyn Thomas (now vice president of Medical Affairs for Transcatheter Heart Valves, Edwards Lifesciences) and my wife were used as “app testers”, and their daily input in to the changes we made were vital.

What has been your most memorable case and why?

For me, a case in which TAVI saved two lives! Essentially a young woman in Muscat (Oman) had undergone aortic and mitral valve replacement in her 20s and chose to have biological valves because she wanted to have children in the future. Unfortunately by the time she got pregnant—nine years later—both her valves were failing. She presented to the local team with heart failure and early pulmonary oedema. She was not able to undergo a redo double-valve procedure because that would terminate the pregnancy while a double valve-valve procedure would expose the foetus to radiation. Therefore, we decided to optimise her medication and wait to see if she could reach third trimester without needing intervention. The team in Muscat did a fantastic job and monitored her and the baby closely, but one day contacted me to say that she was now in pulmonary oedema and could no longer be managed medically. I flew straight to Muscat and the next day, we performed a double valve-in-valve (aortic and mitral) with minimal fluoroscopy and took all the precautions one could to minimise radiation to the foetus. The baby was monitored throughout the procedure and, to our relief, came through the procedure along with the mother. Six weeks later, the baby was born and both the mother and the child are still healthy and happy. I feel this case highlights the true impact of TAVI technology. When I returned, I remember mentioning to my wife that Alain Cribier—the founder of TAVI—should go on the cover of TIME magazine with this story in the background.

Outside of medicine, what are your hobbies and interest?

Photography has been my passion since I was 16. Every year, I have the opportunity to exercise my skills when my family and I go on safari and high altitude treks. The banner and advertisement of PCR London Valves incorporated a picture I had taken of the London Eye. I took at night time when it was covered in fog, which was so thick that Big Ben could not be seen and the long exposure gave me a picture to remember.

I am also a keen sportsman and play several sports, but my favourite sport is golf. I feel golf represents life and that it teaches discipline, honesty and also patience. I think the other advantage is that once you play golf with someone, they become your lifelong friends as you suffer together for at least five hours!